Covering of the Toes During Hindfoot and Ankle Surgery: A Randomized,Controlled,Clinical Study

Background: Major advances in sterility over the last 140 years have dramatically reduced the rates of infection. The purpose of this study was to determine whether there was benefit to covering the toes during hindfoot or ankle surgery. Methods: Forty consecutive hindfoot or ankle surgery patients were randomly assigned to one of two groups based on whether the toes were covered with a sterile glove or left uncovered. Three cultures were taken of the foot in the second web space. The first sample was taken before surgical preparation. The second sample was taken immediately after draping of the patient. The third sample was taken at the conclusion of the operation before dressing placement. The culture swab was moistened before sampling with sterile saline. The operative extremity was scrubbed with chlorhexidine gluconate and sterile water solution, followed by painting with 70% isopropyl alcohol. Before surgery, the patients were assigned to one of the two groups (covered or uncovered toes) on a random basis. A sterile size 6-1/2 glove was placed over the toes of the covered group and left in place until final wound closure. All patients received the same perioperative intravenous antibiotics. Results: Thirty-five of 40 patients (87.5%) had positive cultures before the surgical preparation. One patient had a positive culture at the conclusion of the procedure but not immediately after the surgical preparation, and the toes were covered during the operation. Cultures before and after the procedure contained coagulase negative staphylococcus species. This patient did not develop any wound infection during the followup period. A second patient had positive cultures on all three samples. The species was coagulase positive staphylococcus. This patient did not have any wound infection problems postoperatively, although he was placed on prophylactic antibiotics 8 weeks after the initial surgery for a hardware removal procedure. The toes were not covered during the initial operation in this patient. In total, 10 patients were placed on antibiotics after the initial surgery. Three patients had erythema surrounding the incision, two patients had delayed wound healing, and one patient had erythema at the knee from a proximal tibial bone graft harvest site. The other four patients who received antibiotics had a hardware removal procedure within the 90-day followup period and received prophylactic antibiotics for that procedure. Conclusions: The results of this study indicate no benefits in covering the toes in hindfoot or ankle surgery after skin preparation with chlorhexidine gluconate and isopropyl alcohol. There were only two positive postoperative cultures and neither patient showed any signs of postoperative wound infection during the followup period.